1. Barriers to Safety Event Reporting: Authority Gradients and other Human Factors
Introduction/Problem
Results/Progress to Date
Communication in health care can be affected by differences in professional status, seniority, expertise and experience of team members also known as authority gradients. The existence of an authority gradient represents a significant potential safety risk.
In a survey of over 1,700 health care personnel including nurses, physicians, clinical care staff, and administrators from 13 hospitals across the US, an authority gradient interfered with reporting safety concerns in over 90%.
In December 2014 two adverse events occurred in Radiology in which one member of the team had important information that the remainder of the team was unaware of.
364 of 648 (56%) of employees completed the survey
10 barriers to communicating safety events were evaluated
50% of employees reported being unable to report 100% of safety events which represents a possible unreported safety concerns
The most common barrier to speaking up differed among staff groups
Top three reasons for not speaking up were identified as
High reporting threshold
Not wanting to challenge authority
Fear of disrespect
Aim/Goal
The purpose of this study:
To determine the frequency in which employees speak up with safety concerns; to quantify how often employees are unable to speak up and to identify barriers to speaking up
The Team
Bettina Siewert, MD, Suzanne Swedeen RN, MSN, Mary Hochman, MD, Olga Brook, MD, Ronald L Eisenberg, MD
The Radiology Safety Workgroup
The Interventions
To determine the presences of an authority gradient and other human factors that constitute barriers to speaking up, a new survey tool was developed.
It was felt that the AHRQ Institutional Culture of Safety survey tool would not meet our needs as it collects data on safety attitudes and contributing factors such as staffing and work hours, but does not look at human factors such as fear of disrespect, challenging authority, lack of listening and uncertainty about one’s observation.
The survey contained 20 questions and was void of any identifiable information to protect the respondents’ anonymity with only gender, length of employment and job classification asked.
In preparation for the survey we attended monthly staff meetings in every section and in every job classification to discuss the impact of an authority gradient on patient safety and the importance of the upcoming survey.
The survey was sent out to every Radiology employee in every job classification.
Lessons Learned
While significant safety issues can result when staff are unable to always speak up, the act of speaking up is much harder than one might expect.
50% of employees in Radiology department reported not being able to speak up about safety concerns 100% of the time. The most common root causes for not speaking up consist of a high reporting threshold, not wanting to challenge authority and fear of disrespect.
Cultural changes are needed to support staff towards 100% safety event reporting.
Next Steps
Convene a multidisciplinary workgroup represented by all job classification to better understand the identified barriers to speaking up and to determine targeted interventions to decrease or eliminate barriers.
Suzanne Swedeen RN MSN